Intracranial Hypertension-Related Vision Loss More Common for Men

Action Points

Explain to interested patients that intracranial hypertension involves an increase in intracranial pressure and can result in severe headaches, swelling of the optic nerves, vision loss, double vision, and a whooshing noise in the ears.

Note that the study was retrospective and did not include a sleep study for all patients to determine the role of sleep apnea in the relationship between male gender and vision loss in idiopathic intracranial hypertension.

ATLANTA, Oct. 15 -- Idiopathic intracranial hypertension, although more common in women, is twice as likely to cause severe vision loss in men, researchers found.

In the retrospective study, men were also more likely to report visual changes as their first symptom of the condition, whereas women were more likely to report headache.

Idiopathic intracranial hypertension typically occurs in young, obese women. In the study, only 9% of cases were among men.

These findings suggest that men may not experience the typical symptoms of increased intracranial pressure that would bring them to earlier medical attention and prompt follow-up, said Beau Bruce, M.D., of Emory University, and a co-author of the study.

Men with the condition need to be followed more closely for visual function without relying on them to report symptoms because "they may not reliably experience or report other symptoms of increased intracranial pressure," the researchers recommended.

In an accompanying editorial, Michael Wall, M.D., of the University of Iowa in Iowa City, and Valerie Purvin, M.D., of Indiana University Medical Center in Indianapolis, agreed that men may need more aggressive treatment.

The findings affirmed the suspected role of gender in vision problems but raise more questions than they answer, particularly with regard to obstructive sleep apnea, Drs. Wall and Purvin said.

The retrospective study included medical record review for all 721 consecutive patients with definite idiopathic intracranial hypertension seen at the hospitals of Emory University, the University of Mississippi, and Wayne State University.

Men in the study were more likely than women to also have a diagnosis of sleep apnea (24% versus 4%, P<0.001).

Drs. Wall and Purvin suggested that this difference may have been the real reason behind the gender effect on vision problems with the condition.

"Considering that the mechanism for permanent visual loss in patients with papilledema is related to intraneuronal ischemia at the optic disc," they wrote, "the nocturnal oxygen desaturation, vasospasm, and other circulatory changes associated with sleep apnea could further compromise optic disc perfusion."

The researchers found that men had significantly poorer visual acuity and visual fields than women at both initial and final evaluations.

Controlling for diagnosis of sleep apnea along with age and headache as first sign of idiopathic intracranial hypertension strengthened the association between male sex and severe visual loss in at least one eye (adjusted odds ratio 2.5, P=0.004).

Drs. Wall and Purvin countered that although the researchers were statistically supported in describing male gender as an independent risk factor, sleep apnea was likely underdiagnosed.

"With prospective data collection, we might find that the reason for the poor visual outcome is obstructive sleep apnea rather than being male," they wrote.

Although Dr. Bruce acknowledged that the retrospective study design was a limitation, he suggested that another explanation for the higher prevalence of eye problems among men was the difference in presentation.

Men were significantly older than women at diagnosis (37 versus 28 years, P=0.02).

Their initial symptoms were more likely to be visual changes (35% versus 20%, P=0.004). Only about half noted the characteristic symptom of headache whereas women were more likely to report this as the heralding symptom (75% versus 55%, P<0.001).

Rather than representing a different clinical entity, these differences likely reflect a higher headache threshold among men, the researchers suggested.

Women's longer time to diagnosis suggested they were treated for primary headache disorders before their disease was recognized, which the researchers said "emphasizes the importance of examining the ocular fundi of all patients with headache."

Men may have been more likely to have been first examined by ophthalmologists but later in the course of their disease after chronic papilledema had already led to visual loss, the investigators suggested.

The study was supported in part by a grant from Research to Prevent Blindness and by grants from the National Institutes of Health. One of the researchers reported receiving an award from Research to Prevent Blindness.

The investigators reported no conflicts of interest.

Drs. Wall and Purvin reported support in part by an unrestricted grant from Research to Prevent Blindness and grants from the Veterans Administration

Merit Review but no conflicts of interest.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

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